NCC222947_NOI Signed Certification_20220817

GO1 Notice of Intent (II I) Certification Farm
aIrections
Print this furm, car-opItfle, $Can a d upload to the electronic NQI.
Teen, mail the orWna I form to the NC D EM LR Storm atier Pro grarn (w a h -u check if poying by check i at:
Divisicn of Energy, MineraI & Land Ike&ources St-ormwater PrNrarnti
512 N. Salishury Street, 6- Floor (Offlice 64UK)
1612 Mail Service Center
Raleigh, NC 7699-1612
00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FOAM YOU MAJL MUST - 16IIh L SIGNAT'U RE (NOT 0I15IITAL) [40 CF R 122.221
Per NC Gen ern i SM tote 143.215.6B (i), o ny Person wh u k nowangdy m.a kes an V fa Lse statement, represerrtn tron, o r
celtr tCf iOn in 13DY appikUtiOn, reco Fd,, reps, p+a'n, or ath er documen t fii Led or required to be nsarn tained under (h15
Article Or a rofe fmplemenring this AiTlcte ....soli be gu0ty of a 07.5s 2 nj sdemeanor which ferny include o ,brae not to
exceed tern thousand dallar5 (10,000).
Under penalty of law, I certitV that Icheck all bmesto irrdicote Vaur agree ment)P
I am the per n re sp-nnsible for the construction activities of this ptr�Je , for satisfying the require.ments of kb
} permit' and fur any civil OF criminal penalties incurred due to 00atlons of this permit.
The information submitted in this N 0 1 is, to the best of mar kno wledge and belief true, accurate, and, complete
based on nay inquiry of the person or pers+ s who man age the system, or those persu n s directly responsible for
gather4r g the infor, aUor,
will abide by all condition s of the NCUIDU I CIenf-ral Permit and the approved Erosion and Sediment Control
Plan.
4a If the approved Erosion and Sediment Control Man is not compliant with Part 11 (Storm Ater Pollution
Prevention Plan) of the N U1 U General Permit. I will nonetheless ensure that all corbitinns of Part 11 of the
c rnllt are met on the project at all Mimes,
I hereby request coverage under the NCWICQ� iU 6er,erand understand that co-verage under this
pew it will constitute the permit requirements for the discharge(s) 3rd is enforceable in the sarne manner as an
irid vridual per•ii t.
ru CCt Narne Imusrmetch.Alua, hipotle - Peters Creek Parkway
Specific Lot Numbers (must match Alb)
Perm1ttee (trust rnatch 01): R & M Developanent Servims, LL
LegaRy Responsible person (must match 82 & 83)e Michael S. LaRue
Title of Legat'-y Responsible Person (must match 63b). President
Narne & Title of Signed if Authorized Ind MduaI
Dyers from Legally Respornslble Person:
PhoneNumber:: 336. 317. 0401
S ig n atu rMof legall'y Responsible Person or Au t horlized Individual
11
Date
)WORTANT PVO rE. Th is ,dorm m w r be sign ed h y a rLosp onsible corpor&@ aver that n wn 5 or fawowes the consouctian ezth#pyi
such as a prL—,WerF2, secretary, tronsurer, or arid! prp.;idpnt, Or 0 M0AOger ThOt Is outho riled in accordarKe Mth Part IV, Section 8,
item it;) of the ,WCZJ 06(lo P erM if.